Diagnostic accuracy of upper gastrointestinal series in children with suspected intestinal malrotation

Intestinal malrotation (IM) results from an altered or incomplete rotation of the fetal midgut around the superior mesenteric artery axis. The abnormal anatomy of IM is associated with risk of acute midgut volvulus which can lead to catastrophic clinical consequences. The upper gastro-intestinal series (UGI) is addressed as the gold standard diagnosis procedure, but a variable failure degree has been described in literature. The aim of the study was to analyze the UGI exam and describe which features are the most reproducible and reliable in diagnosing IM. Medical records of patients surgically treated for suspected IM between 2007 and 2020 at a single pediatric tertiary care center were retrospectively reviewed. UGI inter-observer agreement and diagnostic accuracy were statistically calculated. Images obtained with antero-posterior (AP) projections were the most significant in terms of IM diagnosis. Duodenal-Jejunal Junction (DJJ) abnormal position resulted to be the most reliable parameter (Se = 0.88; Sp = 0.54) as well as the most readable, with an inter-reader agreement of 83% (k = 0.70, CI 0.49-0.90). The First Jejunal Loops (FJL), caecum altered position and duodenal dilatation could be considered additional data. Lateral projections demonstrated an overall low sensitivity (Se = 0.80) and specificity (Sp = 0.33) with a PPV of 0.85 and a NPV of 0.25. UGI on the sole AP projections ensures a good diagnostic accuracy. The position of the third portion of the duodenum on lateral views showed an overall low reliability, therefore it was not helpful but rather deceiving in diagnosing IM.

A left-sided approach for wide mobilization of the pancreas with complete dissection of the Treitz ligament (with video)

BACKGROUND

In recent years, the number of minimally invasive pancreatoduodenectomy (MIPD) has been increasing; however, the procedure has not been widely accepted due to its complexity and difficulty. We have developed a technique to mobilize the pancreas head using a left-sided approach with a focus on the complete dissection of the Treitz ligament.

METHODS

This technique focuses on the secure mobilization of the pancreas head using a left-sided approach. First, the transverse mesocolon is flipped upward and the anterior side of the mesojejunum is excised to expose the first jejunal artery (1st JA) from the distal side to its origin. During the procedure, the left sides of the SMA and Treitz ligament are exposed. The Treitz ligament is retracted to the left side and dissected anteriorly. Thereafter, the jejunum is flipped to the right side and the retroperitoneum around the origin of the jejunum and duodenum is dissected to identify the inferior vena cava (IVC). The rest of the Treitz ligament is dissected posteriorly and complete resection of the Treitz ligament releases the limitation of duodenal immobility. Thereafter, dissection proceeds along the anterior wall of the IVC, and mobilization of the pancreas head is completed from the left side.

RESULTS

A total of 75 consecutive patients underwent MIPD from April 2016 to July 2022. The median operation times of laparoscopic and robotic procedures were 528 min (356-757 min) and 739 min (492-998 min), respectively. The volume of blood loss during laparoscopic and robotic procedures was 415 g (60-4360 g) and 211 g (17-1950 g), respectively. There was no mortality in any of the cases.

CONCLUSION

Mobilization of the pancreas head and left-sided approach using a caudal view will be a safe and useful technique for MIPD.

Incidence of late severe intestinal complications after bowel atresia/stenosis

BACKGROUND

To determine the incidence and risk factors for late severe intestinal complications after surgical repair for intra-abdominal congenital intestinal atresia/stenosis.

METHODS

We included 51 patients who underwent surgical repair for congenital intestinal atresia/stenosis. Late severe intestinal complications included adhesive ileus, incisional hernia, or volvulus. Whether surgical intervention was urgent or not was recorded. The location of the atresia/stenosis was classified into two groups: atresia/stenosis located at the oral or anal side from the Treitz ligament. The type of atresia/stenosis was classified as low-risk types (type I, mucosal web/II, fibrous cord/IIIa, mesenteric gap defect) and high-risk types (IIIb, apple peel/IV, multiple atresia). We compared the incidence of late intestinal complications between the location of intestinal atresia/stenosis at the oral and anal side of Treitz ligament, and between low- and high-risk types of atresia/stenosis using Fisher's exact test.

RESULTS

Eight (15.7%) had late intestinal complications, all of which occurred in patients with intestinal atresia/stenosis located on the anal side of the ligament of Treitz. Urgent surgical intervention was needed in four cases. There was a significant difference in the location of atresia/stenosis (with vs. without late intestinal complications at oral/anal side of the Treitz ligament: 0/8 vs. 24/19; P = 0.005) and the type of intestinal atresia/stenosis (with vs. without that accompanying low-/high-risk type: 5/3 vs. 41/2; P = 0.023).

CONCLUSIONS

Physicians should consider the presence of intestinal complications that require surgical intervention in patients undergoing surgical reconstruction for jejunal and ileal atresia/stenosis with abdominal symptoms.

[Laparoscopic pancreaticoduodenectomy with a novel artery first and uncinate process first approach through Treitz ligament]

Objective: To explore the clinical effect of a novel artery first and uncinate process first approach for laparoscopic pancreaticoduodenectomy(LPD), emphasizing the left lateral and posterior dissection of uncinate process (UP) via Treitz ligament approach. Methods: From April to November 2016, 18 patients received LPD with a novel approach in Pancreas Center of the First Affiliated Hospital with Nanjing Medical University. All patients were diagnosed as pancreatic head or peri-ampulla tumor, without major vessel invasion nor distant metastasis. For resection, routine caudal view was used in the first step, to dissect the anterior medial border between uncinate process and superior mesenteric vein(SMV). Lymphatic tissues were completely dissected form anterior surface of hepatoduodenal ligament. In the second step, left lateral view with camera from left para-umbilical trocar was used, Treitz ligament was incised, SMA root was exposed. After anticlockwise rotation and retraction of mesentery, the anatomic relationship between SMA trunk, inferior pancreaticoduodenal artery(IPDA), jejunal branch of SMV, and distal part of UP, could be perfectly exposed from left lateral view. SMA was dissected from its root until the position above the uncinate process and duodenum, IPDA was transected, distal part of UP was freed from SMA. In the third step, right lateral view and caudal view were alternatively used; proximal UP mesentery was completely dissected out from SMA root, CA root and posterior surface of hepatoduodenal ligament. Pancreaticoduodenectomy was completed in the forth step after transection of pancreatic neck and common hepatic duct. Results: The SMA root and distal UP were successfully dissected out via Treitz ligament approach in all 18 patients, among them, distal UP was completely excised in 8 patients from left view. Postoperative pathology showed R0 resection rate in 69%. Postoperative complication included intra-abdominal hemorrhage in 1 patient, pancreatic fistula in 7 patients(6 cases with grade A and 1 case with grade B), delayed gastric emptying in 4 patients (2 cases with grade A, 2 cases with grade B). Average postoperative hospital stay was (15.5±6.8)days. Conclusion: The novel artery first and uncinate process first approach through Treitz ligament could help surgeons to completely dissect the full length of meso-pancreas along celiac axis-SMA axis in LPD.